PAC (Pre-Anaesthetic Check-up) – Description The Pre-Anaesthetic Check-up (PAC) is a systematic evaluation of a patient before administering anaesthesia for surgery or any procedure. It is a critical step in perioperative care that ensures patient safety and optimizes surgical outcomes. --- Key Objectives: Assess medical history, comorbidities, and physical condition Evaluate airway, cardiorespiratory system, and investigations Identify potential anaesthetic risks Plan and customize the anaesthesia technique Obtain informed consent Ensure the patient is fit for anaesthesia and surgery --- Essential Components: 1. Patient Identification & Demographics 2. Medical, Surgical & Drug History 3. Allergies & Substance Use 4. Airway Assessment (e.g., Mallampati grade) 5. Systemic Examination (CVS, RS, CNS) 6. Baseline Investigations 7. ASA Grading 8. Anaesthesia Plan & Risk Discussion

1. PRE ANESTHETIC
CHECKUP
Guide : Dr. Kavya
Presented by :- Dr. Mahima

2. RECAP
.
 CHECK DATES AND INTRODUCTION OF PATIENT
 HISTORY
 PHYSICAL EXAMINATION
 AIRWAY EXAMINATIONS

3. INDEX
1 Definition and Purpose
2 Goals of Assessment
3 Preoperative Medical History
4 Physical Examination
5 Preoperative Risk Assessment
6 Airway Examination
7 METS
8 Lab Investigations
9 Consent
10 Preoperative evaluation for coexisting diseases
11 Periop Medication Management
12 Recap

4. INDEX
1 Definition and Purpose
2 Goals of Assessment
3 Preoperative Medical History
4 Physical Examination
5 Preoperative Risk Assessment
6 Airway Examination
7 METS
8 Lab Investigations
9 Consent
10 Preoperative evaluation for coexisting diseases
11 Periop Medication Management
12 Recap

5. LAB INVESTIGATIONS

9. RHYTHM DISTURBANCES AND ELECTRO
CARDIOGRAPHIC ABNORMALITIES
Arrhythmias and conduction disturbances are common in
perioperative period. Supraventricular and ventricular arrhythmias are
associated with a greater risk of perioperative adverse events because
of arrhythmias itself and because they are markers for cardio
pulmonary disease.
Uncontrolled atrial fibrillation and ventricular tachycardia are high risk
clinical predictors and the elective surgery should be postponed until
evaluation and stabilization are complete. New onset atrial fibrillation,
symptomatic bradycardia, or high grade heart block (2nd
and 3rd
degree) identified in the pre operative clinic warrants consideration of
postponement of elective procedure and referral to cardiology for
further evaluation.

11. INDEX
1 Definition and Purpose
2 Goals of Assessment
3 Preoperative Medical History
4 Physical Examination
5 Preoperative Risk Assessment
6 Airway Examination
7 METS
8 Lab Investigations
9 Consent
10 Preoperative evaluation for coexisting diseases
11 Periop Medication Management
12 Recap

12. INFORMED CONSENT
Written informed consent for each and
every type of anaesthesia
GA
 Local
 Regional
 Intravenous sedation

13. INDEX
1 Definition and Purpose
2 Goals of Assessment
3 Preoperative Medical History
4 Physical Examination
5 Preoperative Risk Assessment
6 Airway Examination
7 METS
8 Lab Investigations
9 Consent
10 Preoperative evaluation for coexisting diseases
11 Periop Medication Management
12 Recap

14. PRE OPERATIVE EVALUATION OF
PATIENTS WITH COEXISTING DISEASE
Cardio vascular disease
Cardio vascular complications are the most common serious perioperative
adverse events. It is estimated the cardiac morbidity will occur in 1% to 5%
of unselected patients undergoing non cardiac surgeries. In specific
circumstances perioperative interventions have been shown to modify
cardio vascular morbidity and mortality.
1. Hypertension: Hypertension defined as 2 or more BP readings >
140/90 mm of Hg. Preoperative evaluation identifies cause of
hypertension, other cardio vascular risk factors, end organ damage and
therapy. Patient with long standing, severe (often based on the number
and doses of prescribed antihypertensive medications), or poorly
controlled hypertension need an ECG and determination of blood urea
nitrogen (BUN) and creatinine depending on the surgical procedure. Those

15. It is generally recommended that elective surgery be delayed for severe
hypertension (diastolic BP > 110 mm of Hg, systolic BP >200 mm of Hg)
until BP < 180/110 mm of Hg.
If severe end organ damage is present the goal should be to normalize
BP as much as possible before surgery. Studies suggest that intra
operative hypotension is far more dangerous then hypertension.
It is important to identify patients who have undiagnosed hypertension
and differentiate those who have poorly controlled hypertension from
those who have episodic increased BP because of pain, anxiety or stress.

16. 2.Ischemic heart disease :
The goal of preoperative evaluation are to -
• Identify the risk of heart disease based on risk factors
• Identify the presence and severity of heart disease from
symptoms, physical findings or diagnostic tests
• Determined need for preoperative interventions
• Modify the risk for perioperative adverse events

17. REVISED CARDIAC RISK INDEX
EACH CLINICAL PARAMETER GIVES A SCORE OF 1 TO REVISED CARDIAC
INDEX =
• High-risk surgeries (intra peritoneal, intra thoracic or supra inguinal
vascular procedures)
• Ischemic heart disease (by any diagnostic criteria)
• History of congestive heart failure
• History of cerebrovascular disease
• Diabetes mellitus requiring insulin therapy
• Serum creatinine level > 2.0 ml/dl

18. REVISED CARDIAC INDEX
CLASS POINTS RISK (%)
I 0 0.4
II 1 0.9
III 2 6.6
IV = OR >3 11

19. NYHA FUNCTIONAL CLASS
Class I No limitation of physical activity; ordinary activity does not cause
fatigue, palpitations or syncope
Class II Slight limitation of physical activity; ordinary activity results in
fatigue, palpitations or syncope
Class III Marked limitation of physical activity; less than ordinary activity
results in fatigue, palpitations or syncope; comfortable at rest
Class IV Inability to do any physical activity without discomfort; SYMPTOMS AT
REST
.

20. PULMONARY DISORDER
1. Asthma: reporting of asthma should prompt further questioning
about shortness of breath, chest tightness, coughing (especially nocturnal),
recent exacerbations, therapy (especially the use of steroids) or oxygen use,
hospitalization, and intubation. The patients exercise level is important
information for assessment of risk.
A history of previous exacerbation with anaesthesia should be elicited.
The quality of breath sounds, quantity of air movement and degree of
wheezing are important. The degree of wheezing does not always
correlate with the severity of bronchoconstriction. With severe
obstruction, airflow is dangerously restricted and wheezing diminishes.
Observing the degree of accessory muscle use often suggests the
severity of the bronchoconstriction.

21. Wheezing is a common symptom in asthmatics but is not specific for this
disease. Patient with COPD, GERD, Vocal cord dysfunction, tracheal or
bronchial stenosis, cystic fibrosis, ABPA and heart failure may wheeze.
Spirometry is the preferred diagnostic test but a normal result does not
exclude asthma. A trial of bronchodilator therapy is indicated if
spirometry is normal but there is still be a strong suspicion of asthma.
A pre operative chest radiograph is necessary only for evaluation of
infections or pneumothorax. Bronchodilator, inhaled and oral steroids
and antibiotics if taken needs to be continued on the day of surgery. Beta
agonists are most useful prophylactic intervention to lower the risk for
bronchospasm on induction of anasthesia.

22. 2. COPD : The preoperative history and physical examination for
patients with COPD are similar to that for the patients with asthma, but
with additional emphasis on the change in amount of sputum, color or
other sign of infection. A barrel chest and pursed lip breathing suggest
advanced disease. Typically FEV1 is reduced because of obstructed airflow,
but FVC is increased because of reduced airflow, loss of elasticity and over
expansion. Diffusing capacity (DLCO) is typically decreased and its severity
often correlates with the degree of hypoxia and hypercarbia, which in turn
can predict the presence of pulmonary hypertension.
A chest radiograph is useful only when infection is suspected. An
ECG may demonstrate right axis deviation, RBBB, or peaked P waves which
suggest pulmonary hypertension and possibly right ventricular changes in
response to the chronic lung disease.

23. PATIENTS WITH UPPER
RESPIRATORY INFECTION
The preoperative evaluation distinguishes patients with more severe
symptoms including purulent secretions, productive cough, temperature
higher then 38 degree C or sign of pulmonary involvement, then elective
surgery should be postponed for about 4 weeks. This period is
suggested because airway hyper reactivity persists for several weeks
after an URI.

24. DIABETES MELLITUS
Diabetics are at risk for multiorgan dysfunction, with renal insufficiency,
stroke, peripheral neuropathy, autonomic dysfunction and
cardiovascular disease being most prevalent. Delayed gastric emptying,
retinopathy and reduced joint mobility occurs in these patients.
Autonomic neuropathy is the best predictor of silent ischemia.
Poor glycemic control is associated with an increased risk for heart
failure and both systolic and diastolic dysfunctions may be present.
Diabetics are at increased risk for renal failure perioperatively and for
post operative infections. Patients with poor preoperative management
of glucose are likely to be more out of control intra operatively and post
operatively. Aggressive management of hyperglycemia decreases post
operative complications.

25. The combination of hypertension, diabetes and
age older than 55 years accounts for more than 90% of the
patients with renal insufficiency. Screening for kidney
disease is accepted practice in patient with diabetes. Patients
with poorly controlled diabetes are at risk for the
development of stiff joint syndrome with reduced cervical
mobility which may influence airway management.
The preoperative evaluation should focus on assessing
organ damage and control of blood sugar. Cardio vascular,
renal and neurological systems need close evaluation.
Documenting pulse, sensory examination and orthostatic
vital signs (BP and HR both lying and standing) are important
in most diabetics, especially those with long standing

26. THYROID DISEASE
Significant hyperthyroidism or hypothyroidism appears to increase
perioperative risk.
HYPERTHYROID patient may have tachycardia, arrhythmias,
palpitations, tremors, weight loss and diarrhea.
HYPOTHYROID patient may be hypotensive, bradycardic and
lethargic and exhibit weight gain, depressed cardiac function, pericardial
effusions and an impaired ventilatory response to hypoxia and
hypercarbia.
Patients with a history of chronic thyroid disease need
thyroid function test before surgery. TSH assays are best to evaluate for
hypothyroidism. Measuring both free T3 and T4 and TSH is useful in
hyperthyroid patients and avoids the confusion of protein binding effects

27. Elective surgery should be postponed until patients are euthyroid.
Surgery, stress or illness can precipitate myxedema or thyroid storm in
patients with untreated or severe thyroid dysfunction.
Preoperative consultation with an endocrinologist should be
considered if surgery is urgent in patients with clinical thyroid
dysfunction. Hyperthyroid patients should be treated with beta
blockers, antithyroid medications, and steroids if surgery is urgent.
Chest radiography or CT scan is useful to evaluate tracheal or
mediastinal involvement by a goiter. Continuation of medications
(thyroid replacement and antithyroid drugs such as propylthiouracil)
on the day of surgery is important.

28. Observing the patient can walk up 1-2 flights of stairs can predict a
variety of post operative complications, including pulmonary and cardiac
events and mortality, and aid in decisions regarding the needs for
further specialized testing such as PFTs or noninvasive cardiac stress
testing.
The pulmonary examination should include auscultation for wheezing
and decreased or abnormal breath sounds and notation of cyanosis or
clubbing, use of accessory muscles, and efforts of breathing.
Obesity, hypertension and large neck circumference (>17 inches in
men, >16 inches in women or >60 cm in anyone) predict an increased
incidence of obstructive sleep apnea (OSA).
These same neck measurements also predict difficulty with mask
ventilation and intubation. Intravenous access sites should be noted if
this is limited, one should discuss possible central line placement.
OSA 17 inch/43 cm in men,16 inch /41 cm in women

30. PREOPERATIVE EVALUATION OF
MORBIDLY OBESE PATIENTS
Obesity is associated with an increased incidence of risk factors
including diabetes and cardio vascular disease. These patients have a
higher incidence of difficult tracheal intubation, decreased arterial
oxygenation, increased gastric volume, more acidic gastric PH, post
operative wound infection, pulmonary embolism and sudden death.
Obesity is an independent risk factor for heart disease,
hypertension, stroke, hyperlipidemia, osteoarthritis, diabetes mellitus,
cancer and OSA are more common in obese people. Obese individual have
increased oxygen consumption and work of breathing but decreased lung
volume and capacity.

31. PREOPERATIVE EVALUATION OF PATIENTS WITH
OSA
Asking patients whether they snore, about the intensity of their
snoring, about observed awakenings or choking, about day time
sleepiness and whether it interferes with activities and about falling
asleep while driving can identify those with probable sleep apnea.
OSA is characterized by total collapse of the airway with
complete obstruction of more than 10 seconds. Obstructive hypopnea is
partial collapse (30%-90%) associated with at least 4 % arterial oxygen
desaturation. The severity of OSA is measured with the apnea-hypoxia
index, or the number of apneic and hypopneic episodes per hour of
sleep. Patients with severe OSA have more than 30 episodes per hour.

32. Mask ventilation, direct laryngoscopy, endotracheal
intubation and even fiberoptic visualization of the airway are
more difficult in patients with OSA than in the healthy
patients. Patients with OSA are more sensitive to the
respiratory depressant effects of opioids than individuals
without OSA.

33. INDEX
1 Definition and Purpose
2 Goals of Assessment
3 Preoperative Medical History
4 Physical Examination
5 Preoperative Risk Assessment
6 Airway Examination
7 METS
8 Lab Investigations
9 Consent
10 Preoperative evaluation for coexisting diseases
11 Periop Medication Management
12 Recap

34. PERIOP MEDICATION
MANAGEMENT
• What to stop (suggestions! - discuss with cons)
• What to keep
• What else to give
.

35. HOLD ON DAY OF SURGERY
• Diuretics
• unless thiazide for hypertension
• unless severe heart failure
• Insulin & OHA
• Vitamins & iron
• ACEI’s or ARB’s (individual choice)
• depends on procedure/risk of hypotension
• Hold sildenafil/tadalafil from night before
.

36. Preop Medicines Management
Stop 48 hours pre-op
NSAIDs
Stop 4 days pre-op
Warfarin (convert to enoxaparin)
Stop 7 days pre-op
Clopidogrel
Aspirin 75 mg usually continued (check with consultant)
Herbal remedies
HRT
.

39. FASTING GUIDELINES
Time before anaesthesia Food or fluid intake
Up to 8 hours Unrestricted
Up to 6 hours Light meal
Up to 4 hours Breast milk
Up to 2 hours Clear liquids only (no solids, no fat)
2 hours pre-anaesthesia Nothing permitted
.

40. THANK
YOU